By Counterforce Health Team in Juxtapid (lomitapide) —

Get Juxtapid (Lomitapide) Covered by Cigna in Virginia: Complete Guide to Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Juxtapid Covered by Cigna in Virginia

Yes, Cigna covers Juxtapid (lomitapide) in Virginia with prior authorization for homozygous familial hypercholesterolemia (HoFH). The fastest path to approval requires: (1) genetic or clinical HoFH documentation, (2) proof of failed PCSK9 inhibitor therapy, (3) baseline liver function tests, and (4) REMS program enrollment. Start today by gathering your genetic test results and prior therapy records, then have your prescriber submit via Cigna's provider portal. If denied, Virginia's Bureau of Insurance provides external review within 45 days. Contact Virginia SCC for appeals guidance at 1-877-310-6560.

Table of Contents

Coverage Basics

Is Juxtapid Covered by Cigna?

Juxtapid (lomitapide) is covered by Cigna plans as a specialty tier medication, but requires prior authorization for all patients. Coverage is specifically limited to patients with genetically or clinically confirmed homozygous familial hypercholesterolemia (HoFH).

Which Cigna Plans Cover Juxtapid?

All Cigna commercial plans in Virginia include Juxtapid on their formularies, typically on the specialty tier. Medicare Advantage plans through Cigna also cover the medication with similar prior authorization requirements.

Coverage Area Details Source
Formulary Status Specialty tier (varies by plan) Cigna Formulary Lists
Required Pharmacy Accredo Specialty Pharmacy only Cigna Specialty Coverage
Prior Authorization Required for all patients Cigna PA Policy

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather HoFH Documentation (Patient/Family)
    • Genetic testing results showing pathogenic variants in LDLR, APOB, PCSK9, or LDLRAP1 genes
    • Or clinical documentation of LDL-C ≥400 mg/dL with family history
    • Timeline: Can take 2-4 weeks if genetic testing needed
  2. Document Prior Therapy Failures (Prescriber)
    • Records of inadequate response to maximum tolerated statins
    • Proof of PCSK9 inhibitor trial (Repatha or Praluent) with failure/intolerance
    • Submit via Cigna Provider Portal
  3. Complete REMS Enrollment (Prescriber)
    • Prescriber certification through Juxtapid REMS program
    • Patient enrollment and counseling documentation
    • Timeline: 1-2 business days
  4. Submit Liver Monitoring Plan (Prescriber)
    • Baseline liver function tests (ALT, AST, bilirubin)
    • Ongoing monitoring schedule per FDA requirements
    • Include in PA submission
  5. Prior Authorization Submission (Prescriber)
    • Complete Cigna PA form with ICD-10 code E78.01
    • Include all documentation from steps 1-4
    • Timeline: 72 hours for standard, 24 hours if urgent
Clinician Corner: Your medical necessity letter should specifically address: confirmed HoFH diagnosis with genetic/clinical evidence, documented inadequate response to maximum lipid-lowering therapy including PCSK9 inhibitors, patient's cardiovascular risk profile, and detailed liver monitoring plan. Reference the FDA prescribing information and include baseline LDL-C levels.

Timing and Urgency

How Long Does Prior Authorization Take?

  • Standard PA: 72 hours from complete submission
  • Urgent PA: 24 hours (requires clinical justification for urgency)
  • Incomplete submissions: May take 5-10 business days for additional information requests

When to Request Expedited Review

Mark your PA as urgent if the patient has:

  • Rapidly worsening cardiovascular symptoms
  • Recent cardiovascular events requiring immediate LDL-C reduction
  • Risk of harm from treatment delay

Clinical Criteria

What Counts as Step Therapy for Juxtapid?

Cigna requires documentation of trials with:

  • Maximum tolerated statin therapy (atorvastatin 80mg or rosuvastatin 40mg preferred)
  • Ezetimibe 10mg daily
  • At least one PCSK9 inhibitor (evolocumab/Repatha or alirocumab/Praluent)
Note: Juxtapid cannot be used concurrently with PCSK9 inhibitors per Cigna policy.

Required Laboratory Documentation

Test Requirement Frequency
LDL-C Baseline and treatment response At initiation, 3 months, then every 6 months
ALT/AST Normal at baseline Monthly for first year, then quarterly
Total bilirubin Normal at baseline With ALT/AST monitoring
Alkaline phosphatase Normal at baseline With ALT/AST monitoring

Costs and Financial Assistance

Understanding Your Costs

Juxtapid typically requires coinsurance rather than a flat copay due to its specialty tier status. Common coinsurance ranges from 10-30% after deductible, which can result in significant monthly costs.

Available Financial Assistance

  • Chiesi Cares Program: Manufacturer assistance for eligible patients
  • Accredo CareTeam: Copay assistance coordination
  • Virginia Medicaid: Coverage available for eligible patients under expanded Medicaid

Contact Accredo at enrollment to discuss all available assistance programs.

At Counterforce Health, we help patients navigate complex prior authorization requirements by analyzing denial letters and crafting targeted appeals with the right clinical evidence. Our platform specializes in turning insurance denials into successful approvals for specialty medications like Juxtapid.

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient HoFH documentation Provide genetic testing or clinical phenotyping Genetic test results or LDL-C ≥400 mg/dL with family history
Incomplete step therapy Document all prior medication trials Pharmacy records, prescriber notes, lab results showing inadequate response
Missing liver monitoring plan Submit detailed monitoring protocol Baseline LFTs, monitoring schedule, prescriber attestation
REMS not completed Complete prescriber and patient enrollment REMS certification documents

Virginia Appeals Process

Internal Appeals (Cigna)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard, 72 hours for expedited
  • How to file: Cigna member portal or written request

External Review (Virginia)

  • Deadline: 120 days after final internal denial
  • Timeline: 45 days for standard, 72 hours for expedited
  • Forms: Form 216-A External Review Request
  • Submit to: Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218
  • Phone: 1-877-310-6560
From our advocates: We've seen many Juxtapid denials overturned on appeal when patients provided comprehensive genetic documentation and detailed prior therapy records. The key is demonstrating that all step therapy requirements were genuinely met with documented failures, not just brief trials. This composite experience reflects common successful appeal strategies, though individual outcomes vary.

Renewals and Reauthorization

When Does Authorization Expire?

Most Cigna prior authorizations for Juxtapid are approved for 12 months. Your prescriber should submit renewal requests 30-60 days before expiration.

What Changes at Renewal?

  • Updated liver function tests required
  • Confirmation of continued medical necessity
  • Documentation of treatment response (LDL-C levels)
  • REMS program compliance verification

Specialty Pharmacy Requirements

Why Must I Use Accredo?

Juxtapid requires specialty pharmacy dispensing due to:

  • FDA REMS program compliance requirements
  • Complex storage and handling needs
  • Required patient counseling and monitoring support

Setting Up Accredo Delivery

Once your PA is approved:

  1. Your prescriber sends the prescription directly to Accredo
  2. Accredo contacts you within 24-48 hours
  3. Complete patient enrollment and counseling
  4. Schedule monthly delivery (temperature-controlled shipping)

Troubleshooting Common Issues

Provider Portal Problems

If the Cigna provider portal is down or unavailable:

  • Fax PA requests to the number listed on your specific plan's PA form
  • Call Cigna provider services for alternative submission methods
  • Ensure you have confirmation of receipt

Missing Forms or Documentation

  • Genetic test results: Contact the testing laboratory for copies
  • Prior therapy records: Request from previous prescribers or pharmacies
  • Insurance verification: Use Cigna member portal or call member services

For complex cases requiring detailed appeals strategy, Counterforce Health specializes in analyzing payer policies and crafting evidence-based appeals that address specific denial reasons with targeted clinical documentation.

Key Terms Glossary

  • PA (Prior Authorization): Insurance approval required before dispensing
  • QL (Quantity Limit): Restrictions on amount dispensed per time period
  • ST (Step Therapy): Requirement to try preferred medications first
  • P2P (Peer-to-Peer): Phone review between prescriber and insurance medical director
  • LMN (Letter of Medical Necessity): Clinical justification for coverage
  • REMS: Risk Evaluation and Mitigation Strategy (FDA safety program)
  • HoFH: Homozygous familial hypercholesterolemia
  • IRO: Independent Review Organization (for external appeals)

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage decisions. For additional support with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.